Physical Diagnosis, M-2 Course


Grant Hutchins, M.D.



Following today's lecture students should understand the following:

1. The challenges of diagnosing obstructive airway disease based on history and physical findings alone. Students should be able to identify commonly used diagnostic maneuvers (i.e. auscultation for wheezing, identification of key historical "asthma triggers", etc.), and discuss the accuracy and limitations of each.

2. The challenges of diagnosing community-acquired pneumonia based on history and physical findings alone. Students should be able to identify commonly used diagnostic maneuvers (i.e. percussion, auscultation, tactile vocal fremitus, history of chest pain, etc.), and discuss the accuracy and limitations of each.



     Mr. Antonio is a 56-year-old white male with a past medical history significant for tobacco abuse (60 pack-year history), essential hypertension and osteoarthritis. He presents to your clinic today for evaluation of a 5-day history of increasing shortness of breath, yellow sputum production and generalized fatigue. He denies hemoptysis but does complain of a low-grade temperature as well as difficulty sleeping because of shortness of breath. He also complains of chest pain when he tries to take a deep breath. Appetite has been poor lately and he ultimately admits to a 10 lb weight loss of the last few months.

     How do you proceed from here?

     A good starting point in any presentation is the generation of a differential diagnosis (DDx). Given the above information your differential might include the following:

1. Pneumonia

2. Bronchitis

3. Congestive heart failure

4. Asthma exacerbation

5. COPD exacerbation

     This list is by no means complete. Are there other diseases that should be included? Why or why not?



     Many times additional history is needed apart from that gained in the initial interview. Are there any questions concerning the above presentation that you would like to ask? A few examples follow:

- Is there any history of the same/similar illness?

- Are there associated symptoms/signs for this illness?

- Does Mr. Antonio have any documented history of pulmonary disease?

- What is his occupation?

- Does he have any hobbies that may contribute to this illness?

- What makes his symptoms better/worse?

- Does he have any unusual travel history?

- Does he have any pertinent past medical history?


Can you think of other questions to ask?



Vitals: BP 150/90, P 100, R 22, T 38.0

General: A thin white male in mild distress

HEENT: No adenopathy, no JVD, no acessory muscle usage noted

CV: Increased rate, regular, II/VI SEM non-radiating, no rubs, gallops or bruits

Pulmonary: Expiratory wheezes throughout, decreased breath sounds in the right base. Right base is dull to percussion. Crackles and egophony are noted on auscultation.

GI: BS present, no rebound or guarding. No masses or bruits.

Extremities/Skin: No C/C/E. Pulses intact. No rashes, sores or open lesions.


     Are there aspects of the exam that you find interesting/valuable? How would you change or modify your DDx at this point?


     You decide to obtain a Z-Pak from your sample closet and treat your patient for community-acquired pneumonia. You astute second-year medical student, however, quickly asks whether or not it is possible to diagnose pneumonia by history and physical exam alone or whether a chest x-ray and further laboratory testing are needed.

     What do you tell him/her?


     How sensitive and specific are the history and physical in diagnosing community-acquired pneumonia?


     Are there particular exam findings/maneuvers that are more helpful than others?


     If your patient had a similar presentation, but had a negative pulmonary exam except for diffuse wheezing on auscultation would that change your differential?


     How sensitive/specific are the commonly used diagnostic maneuvers for obstructive airway disease (i.e. wheezing on auscultation, historical "asthma triggers", etc.)?